Healthcare Provider Details

I. General information

NPI: 1841583291
Provider Name (Legal Business Name): FAMILIA DENTALCLOVIS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2011
Last Update Date: 06/24/2021
Certification Date: 06/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4017 N PRINCE ST
CLOVIS NM
88101-9705
US

IV. Provider business mailing address

2050 E ALGONQUIN RD SUITE 610
SCHAUMBURG IL
60173-4166
US

V. Phone/Fax

Practice location:
  • Phone: 575-762-2757
  • Fax: 575-762-2769
Mailing address:
  • Phone: 847-453-7396
  • Fax: 847-453-7396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MR. BRANDON ALEXANDER TAYLOR
Title or Position: CREDENTIALING & PAYER RELATIONS MGR
Credential: CPCS
Phone: 847-453-7396